Cycle 1
Health 2025-01-16 · Fire 2025-01-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Houston, TX
West Oaks Nursing & Rehab Center
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3625 Green Crest, Houston, TX
(281) 558-1166
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
136
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Touchstone Communities
Operator or chain grouping
Approved since
1995-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,141
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.86
Performance 20.57% · Measure score 1.86 · Achievement 1.86 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.39
Performance 5.93% · Measure score 6.39 · Achievement 6.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.33
Performance 37.80% · Measure score 6.33 · Achievement 6.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.33
Baseline 2.97 hours · Performance 3.21 hours · Measure score 0.33 · Achievement 0 · Improvement 0.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 13.16% · Lower 95% interval 7.25% |
| Discharge to community | 32.14% |
50.57%
18.4 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 13.33% · Lower 95% interval 17.3% |
| Medicare spending per beneficiary | 1.47 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 50 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 10 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 7.84% |
2.29%
5.5 pts worse
|
Numerator 4 · Denominator 51 · Adjusted rate 4.31% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 0.92% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 109 |
| Staff flu vaccination coverage | 10.1% |
42%
31.9 pts worse
|
Numerator 70 · Denominator 693 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36% |
25.2%
10.8 pts better
|
Numerator 9 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.0 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
97.1%
0.2 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.9% · Q3 97.0% · Q4 96.1% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
97.9%
1.2 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
3.3%
3.1 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 7.4% · Q3 4.6% · Q4 3.5% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
18.9%
4.4 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.3% · Q3 15.7% · Q4 16.3% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
10.8%
0.5 pts worse
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 8.6% · Q3 10.5% · Q4 12.1% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.7% |
15.4%
5.7 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 10.0% · Q3 8.6% · Q4 4.4% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.1%
0.4 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 16.2% · Q3 10.0% · Q4 21.9% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
15.0%
1.1 pts worse
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 20.9% · Q3 18.7% · Q4 10.1% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.2%
0.6 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.5% · Q3 2.5% · Q4 3.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
89.7%
7.1 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 96.2% · Q3 97.4% · Q4 96.7% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.0%
0.7 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 13.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
88.0%
8 pts worse
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
25.9%
0.5 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 29.5% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-11-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-19
F · Potential for more than minimal harm
2022-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
E · Potential for more than minimal harm
2023-11-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-11-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-22
D · Potential for more than minimal harm
2022-09-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-14
Penalties and ownership
What sits behind the stars
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Boening, Christopher
Operational/Managerial Control · Individual
Campbell, Leslie
Operational/Managerial Control · Individual
Castillo, Lynnea
Operational/Managerial Control · Individual
Greene, Calandra
Operational/Managerial Control · Individual
Hare, Sondra
Operational/Managerial Control · Individual
International Bank Of Commerce
5% Or Greater Security Interest · Organization
Sehlke, Bryon
Operational/Managerial Control · Individual
Thompson, Johnny
Corporate Officer · Individual
Touchstone Strategies - West Oaks LLC
Operational/Managerial Control · Organization
Zurovec, Darrell
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Park Manor Of Westchase
Houston, TX
1-star overall rating with 1-star inspections with $109,932 in total fines with 10 recent health deficiencies
#2
Avir at Houston
Houston, TX
2-star overall rating with 1-star inspections with $216,791 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Parkway Place
Houston, TX
4-star overall rating with 3-star inspections with $45,741 in total fines with 2 recent health deficiencies
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